SIIM 2017 – Economics of Imaging Informatics

I feel fortunate to chair a very interesting and relevant session during the SIIM 2017 annual meeting this week. The session will focus on the following areas, which are often discussed with clients and industry colleagues.

It seems that there is no well-defined formula or consensus regarding the staffing levels and the structure of an Imaging Informatics Team (IIT). Typical questions are:

  • How large should an IIT be, given the annual Radiology exam volume and number facilities the team supports?
  • In the era of EMRs and IT centralization, what is the right mix of roles between IIT and Corporate IT?
  • How does IT centralization affect IIT financial decision-making and budgets?

James Forrester’s talk will address the above topics, based on his experience at University of Rochester Medical Center.

Another interesting observation is that typically outside of the Director of IIT role, IIT members lack understanding of corporate finance. Even though most significant projects must be budgeted for in advance and any innovation or improvement proposal must be accompanied with a well-crafted business case. Robert (Bob) Coleman’s talk will provide an overview of proven budgeting methods, core components of a good business case, and the required skills to prepare one.

You may also wish to check out this interactive, whiteboard session, which will walk through some common financial models used to evaluate the Total Cost of Ownership (TCO) and Return on Investment (ROI) for imaging IT projects when talking to the CIO.

Looking forward to seeing everybody in Pittsburgh!

SIIM 2017

The Society for Imaging Informatics in Medicine (SIIM) annual meeting will be held on Thu June 1 to Sat June 3, 2017 in Pittsburgh. It has a great program, and by all early accounts, will be one of the best attended in years. See the complete program here. Register to attend here.

Genady and I will be participating.

don-headshot-round

Don K Dennison

Weighing the Options: Enterprise PACS vs. VNA for Enterprise-wide Archiving

Thursday, June 1 | 3:00 pm – 3:30 pm
Science & Innovation Pavilion | Exhibit Hall Theater
#AskIndustry Session

Sharing an imaging archive is generally a good thing, but should you implement one archive and connect multiple PACS and other imaging IT systems to it, or should you build an Enterprise PACS and consolidate your various PACS into it? We will get the perspective of vendor staff that are faced with these types of questions from their customers.

TCB: TCO to the CIO for the CIIP

Friday, June 2 | 8:00 am – 9:30 am
Room 301-302
Whiteboard

The ability of a CIIP to accurately model the Total Cost of Ownership (TCO) for imaging IT application investments and operating costs are critical to getting the support of the CIO, and to getting necessary funding.

In this interactive whiteboard session, “Taking Care of Business: Total Cost of Ownership to the Chief Information Officer for the Certified Imaging Informatics Professional”, attendees will be walked through two scenarios — Multiple PACS Replacement and Consolidation and Cost Model for Shared Enterprise Imaging Platform — by faculty experienced in financial analysis and cost model development.

Combining whiteboard discussion and review of some predefined spreadsheets that provide important calculations for each scenario, this session is intended to be highly interactive with Q&A throughout. The spreadsheets used in the session will be made available to members on the SIIM website following the annual meeting.

genady-headshot-round

Genady Knizhnik

Economics of Imaging Informatics

Friday, June 2 | 4:15 pm – 5:15 pm
Pittsburgh Ballroom B
Core Topic Session

Imaging informatics teams routinely embark on new projects and have to support their operations, which depend on the right budget. Budget preparation and justification skills, as well as understanding of the right size and structure of the operational team, are important for securing required financial support. Attendees will examine the fundamentals of preparing well-defined budget requests that CIOs are looking for, as well as how to structure and staff the optimal imaging informatics team.

SIIM 2016: Where’s Don

SIIM2016

SIIM 2016 is almost here. If you are attending this year’s Annual Meeting, you may find these sessions that I am chairing of interest.

Developing an Imaging Record Quality Policy
Thursday, June 30 | 1:15 pm – 2:45 pm
Portland Ballroom 256

Strategies and Tactics for Capturing and Sharing Images
Friday, July 1 | 8:00 am – 9:30 am
Portland Ballroom 256

Strategies for Dealing with Patient Identities in a Consolidated Enterprise
Friday, July 1 | 1:15 pm – 2:45 pm
Portland Ballroom 256

Basically, just park yourself in Portland Ballroom 256 and I will come to you.

I will also be participating in the:

Hackathon Project Showcase (#SIIMHacks)
Friday, July 1 | 9:45 am – 10:45 am | Portland Ballroom 254

I look forward to catching up with some old friends and making some new ones over some craft beer!

What can Enterprise Imaging Learn from Radiology?

Radiology Information Interoperability for Productivity and Quality

In the early days of Radiology, data entry errors by Radiology Technologists (aka Techs) were common. Their attention was on the patient and the operation of the modality, not the clerical task of typing in data, after all. To address this, something called a DICOM Modality Worklist (aka DMWL) was developed and adopted.

Essentially, this took the textual patient and imaging procedure order information entered into the HIS or RIS (i.e. the order placer), and sent it to some system as an HL7 ORM message (an order). The structured patient/order information was then provided to modalities using the DICOM protocol (because this is the language they speak). DMWL could be provided by the RIS or PACS or some form of broker system that spoke both HL7 and DICOM.

This allowed trained clerical workers (or physicians), combined with software that validated the data entered (where it could), to pass the information to the modality workstation where it could be mapped into DICOM objects, without having to ask Techs to enter this info. The productivity and information quality gains were significant.

It is worth noting that the order provides other value than just eliminating duplicate data entry. It represents a work instruction, and it is used in scheduling and billing. Where image acquisition is not scheduled or billed for, orders are typically not created.

Enter Enterprise Imaging

As we enter the era of Enterprise Imaging, there are lots of lessons that we can learn from the solved problems in areas like Radiology.

For example, when capturing a photo in a Wound Care clinic, it has to be associated with the correct patient (obviously), but there is likely other pertinent info that should be captured, such as the anatomical region imaged and any observations by the physician.

In Enterprise Imaging, orders are often not placed. In many areas, the imaging is often not the primary task, but one that used to support clinical work.

If orders are not placed, how can we at least provide the benefit of passing textual patient data to the image capture device or application to reliably associate patient (and perhaps encounter or procedure) data?

Even if orders are placed, most of the devices and applications used in Enterprise Imaging cannot accept an HL7 message and do not speak DICOM. Some form of broker would likely be required yet again.

Enterprise Information Interoperability for Enterprise Image Capture

One hope that we have is the adoption of the new HL7 FHIR standard. Based on REST-based API design methods, it is much easier to integrate with different devices (especially mobile devices) than HL7 v2.x messaging and DICOM interfaces are. Other methods used are to generate a URL from the EMR, with all the info provided in parameters, that launches the image capture application/device in context. Another method is to use HL7 messaging to populate the VNA database with patient, encounter and order/procedure information (essentially a copy of what the EMR has), and use a tool or API (perhaps the DICOMweb™ Query API, QIDO-RS) to query this system to get the necessary information.

Don’t Forget the Metadata and Supporting Information

This still leaves the issue of how to reliably and consistently capture the information that goes with the image(s)—notes, anatomy info, findings, technical exam info, observations, etc. In DICOM, when this type of information is needed, a SOP Class is defined. The header of the SOP Class object specifies where all this metadata should go. This is one of the primary principles of interoperability: a defined format and data scheme, with a clear and shared meaning.

Assuming that not all Enterprise Images will be generated in, or converted into, DICOM format, the definition of the metadata schema may be left to be defined by the implementing vendor.

In addition to the clinical and technical data, sooner or later, someone is going to be looking for operational data for use in analytics and process improvement, so it will need to be captured (on some level of detail), as well.

Consistent Terms

And, even when we have a common schema, if the terms used within the scheme are not consistent, we end up spending an enormous amount of time doing mappings or integrating terminology services (and even then, never fully addressing all cases).

To Acquire or Not to Acquire

If we think about Enterprise Imaging that is not “ordered”, what triggers the acquisition of an Enterprise Image? Is it up to the clinic or individual care provider to make the judgement? Should a published set of best practices define this? Would the EMR have logic, based on the patient’s condition or care pathway, to prompt or force the user to acquire and store the image(s)?

Enterprise Imaging Acquisition Protocols Needed?

If we consider the different ways that images can be captured (still, video), the subject in frame (cropping, zooming), lighting, etc., and the ability to capture a single image or a set of images, do we also need some form of a book of protocols to guide the person acquiring the images? Should certain images contain a ruler (or object of known size) to allow the image to be calibrated for measurements?

The Cost of Doing Nothing

If we consider the impact of not having methods to avoid data entry errors, or not having a common schema, not having common terms, and not even having a common communication protocol or best practices for acquisition workflows, what hope does Enterprise Imaging have?

Even with options for all these things, imaging and information devices are still struggling to be interoperable with departmental and enterprise applications, as described in this Healthcare IT News article, “Nurses blame interoperability woes for medical errors”.

The Future is Now(ish)

This is why the mission and output of the joint HIMSS-SIIM Enterprise Imaging workgroup (charter in PDF here) is so important. The space needs to be better defined, with acquisition workflow practices, data formats, schemas, terms, and protocols outlined.

If we simply try to copy what is done in Radiology into Enterprise Imaging, it will create too much of a burden on the people asked to capture these images, and they won’t do it, frankly. Unlike the reimbursement in Radiology, they often have little incentive to spend the extra time to capture, index and upload images to the EMR when they are focused on the patient.

But, if we ignore the benefits that come with the controls and methods we have developed and matured over the years in Radiology, we risk having to re-learn all the same lessons again. And that would be very sad (and expensive, and wasteful, and unsafe…).

Add on top of all this the increasing need to share this data across different enterprises for continuity of care and the importance of interoperable data portability/liquidity is critical.

The fundamental healthcare informatics knowledge and business analysis skills developed by imaging informatics professionals, through on-the-job experience and membership in educational/research societies like SIIM, will be important in determining the right mix of proven concepts that apply, and new methods and innovations. Without a supply of talent to foster the change, nothing will change.

In Conclusion…

When dealing with such an undefined space, people often relish the idea of “doing it right this time”. I would urge anyone involved in this space to reflect on what has been accomplished in mature fields like Radiology, as there are a lot of “right things” that we may be taking for granted. With a little modernization, we can still get continued value out of what we have already achieved.

Enterprise Imaging – New HIMSS-SIIM Workgroup

The discussion of so called Enterprise Imaging is a hot topic. So I was very excited to read about the newly announced joint workgroup between HIMSS and SIIM. I believe it holds a lot of promise.

In my experience, there is no lack of technical solutions for capturing, managing, discovering, accessing and viewing enterprise images and related information. The challenge is discovering and sharing the knowledge on best practices of how to put it all together and how to operate the systems that manage this information.

Like diagnostic imaging exams, enterprise images are part of the patient’s medical record, so understanding how they should best be incorporated into the EMR is very important. And this is not just a technical discussion, there are lots of issues around policies and governance of the data that organizations—not their vendors—have to get a handle on.

This is why this workgroup is so important. HIMSS knows all about EMR solutions, and SIIM knows imaging informatics. A perfect marriage.

Article – SIIM: Experiment in web technologies points to future of health IT

Here is an article summarizing the way Cleveland Clinic is using REST-based APIs to solve real problems in their institution. Taken from a talk given by Mat Coolidge at the SIIM 2014 Annual Meeting.